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[SALON & SPA] New Client Intake & Health History

[SALON & SPA] New Client Intake & Health History

It is important to answer the questions as best as possible to ensure that you receive adapted treatments, taking into consideration your personal and individual health. Thank you.

[ENTER BUSINESS NAME, ADDRESS]
Phone: (123) 456-6789
Email: YourName@YourEmail.com
Website: YourWebsite.com
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  • YOUR HEALTH HISTORY

    This health history below will be reviewed by your esthetician (if necessary).

    We may periodically ask you to complete a new health history form to monitor any new changes to your overall health which may affect the nature of the treatments you are receiving.

    Please be sure to inform us of any changes prior to each visit.

    Please answer each question as accurately as possible
  • Please choose the best answer for each question below: *
      Yes No
    Do you wear contact lenses or glasses
    Are you allergic to latex
    Asthma, hayfever, seasonal allergies
    Cold hands and or feet
    Varicose veins
    Low blood pressure
    High blood pressure
    High anxiety and nervousness
    Excessive sweating
    Prone to sore throats
    Prone to earaches
    Diabetes
    Osteoarthritis
    Osteoporosis
    Recent treatment with a plastic surgeon
    Recent treatment with a dermatologist
  • Have you, or are you currently taking the following medications: *
      Yes No
    Accutane
    Glycolic Acid
    High Blood Pressure
    Thyroid Medication
    Alpha Hydroxy Acid product
    Cortisone
    Retin-A (in the last six months)
    Tetracycline
    vitamin A derivatives
  • YOUR SKIN

    Please answer the following
  • Please answer the following: *
      Yes No
    Do you tan indoors (tanning bed)
    Do you tan outdoors
    Have you had a bad sunburn before
    Do you smoke
    Are you a vegetarian
    Are you a vegan
    Do you follow a special diet
  • Capillary activity: *
      Yes No
    In moderate sunlight, do you easily burn?
    When nervous, do you blush easily?
    Do you have a tendency to redness?
    Are up prone to sinus problems?
  • FEMALE clients only
      Yes No
    Are you pregnant or trying to become pregnant?
    Are you lactating?
    Are you taking oral contraception?
    Are you premenopausal?
    Are you menopausal?
    Are you postmenopausal?
  • MALE clients only
      Yes No
    Do you ever experience skin irritation from shaving?
    Are you prone to ingrown hairs?
    Do you use an electrical shaver
    Do you wet shave? (razor blade)
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  • DEAR CLIENT, PLEASE SCROLL DOWN TO THE BOTTOM AND SUBMIT YOUR FORM

    (the info below is for OFFICE USE ONLY. Do not enter any info please)

    Esthetician or Practioner notes for appointments
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